I have answered these questions to the best of my knowledge.

1. I consent to the necessary diagnostic procedures (including x-rays) to determine if root canal therapy is indicated. If root canal therapy is indicated, I will decide whether or not I wish to have treatment.

2. I understand that root canal treatment is an attempt to save a tooth that may otherwise require extraction. Although root canal therapy has a high degree of success, it is a dental-biological procedure whose results cannot be guaranteed. Occasionally, a tooth that has had root canal therapy may require retreatment, corrective surgery, or even extraction.

3. Treatment may require multiple visits. It is important that you maintain the scheduled appointments or infection and/or swelling may occur.

4. In most cases, there is only slight to moderate discomfort following each treatment. Severe post-treatment pain occurs in very few cases. This is usually controlled with Aspirin, Tylenol, Ibuprofen, or prescribed medications.

5. The most common complications with root canal therapy include, but are not limited to:

1. Continued infection, requiring endodontic surgery or extraction of the tooth.
2. Facial swelling requiring the use of antibiotics, surgical incision & drainage, or extraction of the tooth.
3. Calcified canals or canals blocked by broken instruments, requiring endodontic surgery or extraction of the tooth.
4. Pain, requiring the use of medication.
5. Side effects and reactions to medication such as allergies, nausea, vomiting, or diarrhea.
6. Fractures of the root or crown of the tooth during or after treatment. It is recommended that all posterior teeth be crowned following root canal treatment.
7. Fracture and loss of root canal treated tooth due to brittleness may be more likely to occur unless the tooth is restored.
8. If your tooth already has a crown, there is a chance it will need to be replaced due to decay or loss of structural support. Porcelain crowns are subject to break. Any crown may come off during treatment.
9. Tenderness of the tooth following treatment due to possible complications with root canal treatment, gum disease, physical stress of chewing, or the degree of healing your body exhibits.

6. Accurate and complete disclosure of medical information is necessary for proper diagnosis, and to help prevent unnecessary complications during your treatment. Some antibiotics may interfere with the effectiveness of oral contraceptives (birth control pills). Women who are taking contraceptives, and are given a prescription of an antibiotic, are strongly advised to use additional means of birth control during the entire monthly cycle.

 

7. Other treatment choices include: No treatment, waiting for more definitive development of symptoms, and tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth, malocclusions, and infections to other areas.

8. Your referring dentist will advise you on the restorative phases of treatment and the financial investment involved.

9. It is your responsibility to contact your dentist for restoration of root canal treated tooth/teeth.

10. It is your responsibility to contact this office for follow-up visits.

11. The procedure(s) necessary to treat the condition(s) have been explained to me and I understand the nature of the procedure to be endodontic (root canal) therapy.

My signature below indicates that I have read (or have had read to me) and understand this consent form. I have been given the opportunity to ask questions and all questions have been answered in a complete and satisfactory manner. This consent does not encompass the entire discussion I had with the doctor and his assistant regarding proposed treatment.

PAYMENT:
PAYMENT FOR ALL SERVICES IS DUE AT THE TIME OF YOUR APPOINTMENT. OUR FRONT OFFICE STAFF IS COMMITTED TO GUIDING YOU IN CHOOSING THE BEST PAYMENT OPTION TO MEET YOUR INDIVIDUAL NEEDS. WE ACCEPT, VISA, MASTERCARD, DISCOVER, AM EX, CARE CREDIT, CASH, OR CHECK AS FORMS OF PAYMENT. IF YOU ARE UNABLE TO MAKE PAYMENT AT THE TIME OF YOUR APPOINTMENT, IT MAY BE NECESSARY TO RESCHEDULE YOUR APPOINTMENT FOR A TIME IN WHICH PAYMENT WILL BE MORE COMFORTABLE FOR YOU.

DENTAL INSURANCE:
I AUTHORIZE THE OFFICE OF DR. DANIEL BARTON TO RELEASE ANY PROTECTED HEALTH INFORMATION NECESSARY TO PROCESS MY DENTAL INSURANCE CLAIM. YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. WE ARE NOT A PARTY TO THAT CONTRACT. IF GIVEN THE CORRECT INSURANCE INFORMATION, OUR EXPERIENCED STAFF WILL FILE YOUR INSURANCE CLAIM ON YOUR BEHALF. IF YOUR INSURANCE HAS OUT OF NETWORK BENEFITS, PAYMENT FOR THESE SERVICES WILL BE REIMBURSED TO YOU. IF THERE ARE QUESTIONS REGARDING THE PROCESSING OR PAYMENT OF YOUR DENTAL CLAIM, WE SUGGEST THAT YOU CONTACT YOUR INSURANCE COMPANY DIRECTLY. WE FILE INSURANCE CLAIMS AS A COURTESY TO OUR PATIENTS, BUT YOUR CLAIM IS STILL YOUR RESPONSIBILITY.

ACCOUNT COLLECTIONS:
IF IT BECOMES NECESSARY TO SEEK A COLLECTION AGENCY TO RECEIVE PAYMENT FROM YOU, YOUR ACCOUNT WILL BE CHARGED A FEE OF $25. IT WILL BE YOUR RESPONSIBILITY FOR ANY COSTS RELATED TO THE COLLECTION OF YOUR ACCOUNT. THERE IS A $25 RETURN CHECK FEE FOR ANY CHECK THAT IS RETURNED TO US UNPAID.

 

MINOR PATIENTS:
THE PARENT OR ADULT ACCOMPANYING A MINOR PATIENT TO THEIR APPOINTMENT IS RESPONSIBLE FOR ANY PAYMENT DUE AT THAT TIME. IF THE PATIENT IS A MINOR, PLEASE LIST YOUR NAME AND SS# HERE:

MY SIGNATURE BELOW INDICATES THAT I HAVE READ, UNDERSTAND AND AGREE TO THIS FINANCIAL POLICY AND MAY REQUEST A COPY OF THIS AGREEMENT.

A COPY OF OUR PRIVACY PRACTICES ARE LOCATED IN OUR LOBBY. YOU MAY REQUEST A PRINTED COPY IF YOU PREFER. I HAVE READ OR RECEIVED A COPY OF THIS OFFICE’S NOTICE OF PRIVACY PRACTICES.